1
|
Butensky AM, Desai S, Dilorenzo M, Lytrivi ID, Mantell BS, Zhang Y, Choudhury TA. Association Between High Sensitivity Troponin Levels Following Pediatric Orthotopic Heart Transplantation and Intensive Care Unit Resource Utilization. Pediatr Cardiol 2024; 45:829-839. [PMID: 38424311 DOI: 10.1007/s00246-024-03424-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 01/18/2024] [Indexed: 03/02/2024]
Abstract
The utility of troponin levels, including high sensitivity troponin T (hs-TnT), after orthotopic heart transplant (OHT) is controversial. Conflicting data exist regarding its use as a marker of acute rejection. Few studies have examined possible associations of hs-TnT levels immediately after OHT with metrics of intensive care unit (ICU) resource utilization or risk of acute rejection. We performed a retrospective cohort chart review including all OHT recipients < 20 years of age at our center between June 2019 and December 2022. Patients were divided into two groups based on supra- or sub-median initial hs-TnT levels (median 3462.5 ng/L). Primary outcome was days requiring ICU-level care, secondary outcomes included days intubated, days requiring positive pressure ventilation (PPV), days on inotropic medications, actual ICU length of stay, Vasoactive Inotrope Scores (VIS) on postoperative days (POD) 0 through 7, and acute rejection at 30 days and one year after OHT. Patients with higher hs-TnT required ICU level care for longer [13.5 (10-17.5) vs. 9.5 (8-12) days, p = 0.01] and spent more days intubated [6 (4-7) vs. 3 (3-5) days, p < 0.001], on PPV [9 (6-15) vs. 6 (5-8.5) days, p = 0.02], and on inotropes [11 (9-14) vs. 8 (7-11) days, p = 0.025]. VIS was only different between groups on POD7 [5 (3-7) vs. 3 (0-5), p = 0.04]. There was no difference in rejection between the groups. Higher hs-TnT immediately following pediatric OHT may predict higher ICU resource utilization, despite no difference in VIS, although it does not predict acute rejection in the first year after OHT.
Collapse
Affiliation(s)
- Adam M Butensky
- Division of Cardiology, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons and NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, NY, USA.
| | - Shyam Desai
- Division of Cardiology, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons and NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, NY, USA
| | - Michael Dilorenzo
- Division of Cardiology, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons and NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, NY, USA
| | - Irene D Lytrivi
- Division of Cardiology, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons and NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, NY, USA
| | - Benjamin S Mantell
- Division of Cardiology, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Yun Zhang
- Division of Cardiology, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons and NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, NY, USA
| | - Tarif A Choudhury
- Division of Cardiology, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons and NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, NY, USA
| |
Collapse
|
2
|
Alpha-cardiac Actin Serum Expression Levels Detect Acute Cellular Rejection in Heart Transplant Patients. Transplantation 2023; 107:466-474. [PMID: 35939381 PMCID: PMC9875841 DOI: 10.1097/tp.0000000000004273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Given the central role of sarcomeric dysfunction in cardiomyocyte biology and sarcomere alterations described in endomyocardial biopsies of transplant patients with rejection, we hypothesized that the serum expression levels of genes encoding sarcomeric proteins were altered in acute cellular rejection (ACR). The aim of this study is to identify altered sarcomere-related molecules in serum and to evaluate their diagnostic accuracy for detecting rejection episodes. METHODS Serum samples from transplant recipients undergoing routine endomyocardial biopsies were included in an RNA sequencing analysis (n = 40). Protein concentrations of alpha-cardiac actin were determined using a specific enzyme-linked immunoassay (n = 80). RESULTS We identified 17 sarcomeric genes differentially expressed in patients with clinically relevant rejection (grade ≥2R ACR). A receiver operating characteristic curve was done to assess their accuracy for ACR detection and found that 6 relevant actins, myosins, and other sarcomere-related genes showed great diagnostic capacity with an area under the curve (AUC) > 0.800. Specifically, the gene encoding alpha-cardiac actin ( ACTC1 ) showed the best results (AUC = 1.000, P < 0.0001). We determine ACTC1 protein levels in a larger patient cohort, corroborating its overexpression and obtaining a significant diagnostic capacity for clinically relevant rejection (AUC = 0.702, P < 0.05). CONCLUSIONS Sarcomeric alterations are reflected in peripheral blood of patients with allograft rejection. Because of their precision to detect ACR, we propose sarcomere ACTC1 serum expression levels as potential candidate for to be included in the development of molecular panel testing for noninvasive ACR detection.
Collapse
|
3
|
Liu Z, Perry LA, Penny-Dimri JC, Handscombe M, Overmars I, Plummer M, Segal R, Smith JA. Elevated Cardiac Troponin to Detect Acute Cellular Rejection After Cardiac Transplantation: A Systematic Review and Meta-Analysis. TRANSPLANT INTERNATIONAL : OFFICIAL JOURNAL OF THE EUROPEAN SOCIETY FOR ORGAN TRANSPLANTATION 2022; 35:10362. [PMID: 35755856 PMCID: PMC9215116 DOI: 10.3389/ti.2022.10362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 05/17/2022] [Indexed: 11/13/2022]
Abstract
Cardiac troponin is well known as a highly specific marker of cardiomyocyte damage, and has significant diagnostic accuracy in many cardiac conditions. However, the value of elevated recipient troponin in diagnosing adverse outcomes in heart transplant recipients is uncertain. We searched MEDLINE (Ovid), Embase (Ovid), and the Cochrane Library from inception until December 2020. We generated summary sensitivity, specificity, and Bayesian areas under the curve (BAUC) using bivariate Bayesian modelling, and standardised mean differences (SMDs) to quantify the diagnostic relationship of recipient troponin and adverse outcomes following cardiac transplant. We included 27 studies with 1,684 cardiac transplant recipients. Patients with acute rejection had a statistically significant late elevation in standardised troponin measurements taken at least 1 month postoperatively (SMD 0.98, 95% CI 0.33–1.64). However, pooled diagnostic accuracy was poor (sensitivity 0.414, 95% CrI 0.174–0.696; specificity 0.785, 95% CrI 0.567–0.912; BAUC 0.607, 95% CrI 0.469–0.723). In summary, late troponin elevation in heart transplant recipients is associated with acute cellular rejection in adults, but its stand-alone diagnostic accuracy is poor. Further research is needed to assess its performance in predictive modelling of adverse outcomes following cardiac transplant. Systematic Review Registration: identifier CRD42021227861
Collapse
Affiliation(s)
- Zhengyang Liu
- Department of Anaesthesia, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Luke A Perry
- Department of Anaesthesia, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Jahan C Penny-Dimri
- Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia
| | - Michael Handscombe
- Department of Anaesthesia, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Isabella Overmars
- Infection and Immunity Theme, Murdoch Children's Research Institute, Parkville, VIC, Australia
| | - Mark Plummer
- Department of Intensive Care Medicine, Royal Melbourne Hospital, Parkville, VIC, Australia.,Department of Medicine, University of Melbourne, Parkville, VIC, Australia
| | - Reny Segal
- Department of Anaesthesia, Royal Melbourne Hospital, Parkville, VIC, Australia.,Department of Medicine, University of Melbourne, Parkville, VIC, Australia
| | - Julian A Smith
- Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia
| |
Collapse
|
4
|
Tokavanich N, Sinphurmsukskul S, Kongruttanachok N, Thammanatsakul K, Sritangsirikul S, Ariyachaipanich A, Ongcharit P, Siwamogsatham S, Boonyaratavej S, Puwanant S. Circulating growth differentiation factor-15 as a novel biomarker in heart transplant. ESC Heart Fail 2021; 8:3279-3285. [PMID: 34110100 PMCID: PMC8318448 DOI: 10.1002/ehf2.13471] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 05/20/2021] [Accepted: 06/01/2021] [Indexed: 12/19/2022] Open
Abstract
Aims This study aimed to examine (i) whether circulating growth differentiation factor‐15 (GDF‐15) is associated with acute cellular cardiac allograft rejection (ACR); (ii) a longitudinal trend of GDF‐15 after heart transplantation; and (iii) the prognostic value of GDF‐15 in predicting a composite outcome of severe primary graft dysfunction (PGD) and 30 day mortality post‐transplant. Methods and results Serum samples were collected before heart transplantation and at every endomyocardial biopsy (EMB) post‐heart transplantation in de novo transplant patients. A total of 60 post‐transplant serum samples were matched to the corresponding EMBs. Seven (12%) were considered International Society for Heart Lung Transplantation Grade 1R ACR, and one (2%) was identified as Grade 2R ACR. GDF‐15 levels in patients with ACR were not different from those in the non‐rejection group (6230 vs. 6125 pg/mL, P = 0.27). GDF‐15 concentration gradually decreased from 8757 pg/mL pre‐transplant to 5203 pg/mL at 4 weeks post‐transplant. The composite adverse outcome of PGD and 30 day mortality was significantly associated with increased post‐operative GDF‐15 (odds ratio: 40; 95% confidence interval: 2.01–794.27; P = 0.005) and high inotrope score post‐transplant (odds ratio: 18; 95% confidence interval: 1.22–250.35; P = 0.01). Conclusions Circulating GDF‐15 concentration was markedly elevated in patients with end‐stage heart failure and decreased after heart transplantation. GDF‐15 was significantly associated with post‐transplant PGD and mortality. A lack of association between ACR and GDF‐15 did not support routine use of GDF‐15 as a biomarker to detect ACR. However, GDF‐15 may be potentially useful to determine heart transplant recipients at high risk for adverse post‐transplant outcomes. We suggest that GDF‐15 levels in recipient serum can provide risk stratification for severe PGD including death during post‐operative period. This novel biomarker may serve to inform and guide timely interventions against severe PGD and adverse outcomes during the first 4 weeks after transplantation. Further studies to support the utility of GDF‐15 in heart transplantation are required.
Collapse
Affiliation(s)
- Nithi Tokavanich
- Division of Cardiovascular Medicine, Department of Medicine, Faculty of Medicine, Chulalongkorn University, 1873 Rama IV Rd, Pathumwan, Bangkok, 10330, Thailand
| | - Supanee Sinphurmsukskul
- Excellent Center for Organ Transplantation, King Chulalongkorn Memorial Hospital, the Thai Red Cross Society, Bangkok, Thailand
| | - Narisorn Kongruttanachok
- Department of Laboratory Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Kanokwan Thammanatsakul
- Excellent Center for Organ Transplantation, King Chulalongkorn Memorial Hospital, the Thai Red Cross Society, Bangkok, Thailand
| | - Supaporn Sritangsirikul
- Excellent Center for Organ Transplantation, King Chulalongkorn Memorial Hospital, the Thai Red Cross Society, Bangkok, Thailand
| | - Aekarach Ariyachaipanich
- Division of Cardiovascular Medicine, Department of Medicine, Faculty of Medicine, Chulalongkorn University, 1873 Rama IV Rd, Pathumwan, Bangkok, 10330, Thailand.,Excellent Center for Organ Transplantation, King Chulalongkorn Memorial Hospital, the Thai Red Cross Society, Bangkok, Thailand
| | - Pat Ongcharit
- Cardiac Center, King Chulalongkorn Memorial Hospital, the Thai Red Cross Society, Bangkok, Thailand.,Division of Cardiothoracic Surgery, Department of Surgery, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Sarawut Siwamogsatham
- Division of Cardiovascular Medicine, Department of Medicine, Faculty of Medicine, Chulalongkorn University, 1873 Rama IV Rd, Pathumwan, Bangkok, 10330, Thailand.,Chula Clinical Research Center, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Smonporn Boonyaratavej
- Division of Cardiovascular Medicine, Department of Medicine, Faculty of Medicine, Chulalongkorn University, 1873 Rama IV Rd, Pathumwan, Bangkok, 10330, Thailand.,Cardiac Center, King Chulalongkorn Memorial Hospital, the Thai Red Cross Society, Bangkok, Thailand
| | - Sarinya Puwanant
- Division of Cardiovascular Medicine, Department of Medicine, Faculty of Medicine, Chulalongkorn University, 1873 Rama IV Rd, Pathumwan, Bangkok, 10330, Thailand.,Excellent Center for Organ Transplantation, King Chulalongkorn Memorial Hospital, the Thai Red Cross Society, Bangkok, Thailand.,Cardiac Center, King Chulalongkorn Memorial Hospital, the Thai Red Cross Society, Bangkok, Thailand
| |
Collapse
|
5
|
Non-invasive cardiac allograft rejection surveillance: reliability and clinical value for prevention of heart failure. Heart Fail Rev 2020; 26:319-336. [PMID: 32889634 DOI: 10.1007/s10741-020-10023-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/31/2020] [Indexed: 01/04/2023]
Abstract
Allograft rejection-related acute and chronic heart failure (HF) is a major cause of death in heart transplant recipients. Given the deleterious impact of late recognized acute rejection (AR) or non-recognized asymptomatic antibody-mediated rejection on short- and long-term allograft function improvement of AR surveillance and optimization of action strategies for confirmed AR can prevent AR-related allograft failure and delay the development of cardiac allograft vasculopathy, which is the major cause for HF after the first posttransplant year. Routine non-invasive monitoring of cardiac function can improve both detection and functional severity grading of AR. It can also be helpful in guiding the anti-AR therapy and timing of routine surveillance endomyocardial biopsies (EMBs). The combined use of EMBs with non-invasive technologies and methods, which allow detection of subclinical alterations in myocardial function (e.g., tissue Doppler imaging and speckle-tracking echocardiography), reveal alloimmune activation (e.g., screening of complement-activating donor-specific antibodies and circulating donor-derived cell-free DNA) and help in predicting the imminent risk of immune-mediated injury (e.g., gene expression profiling, screening of non-HLA antibodies, and circulating donor-derived cell-free DNA), can ensure the best possible surveillance and management of AR. This article gives an overview of the current knowledge about the reliability and clinical value of non-invasive cardiac allograft AR surveillance. Particular attention is focused on the potential usefulness of non-invasive tools and techniques for detection and functional grading of early and late ARs in asymptomatic patients. Overall, the review aimed to provide a theoretical and practical basis for those engaged in this particularly demanding up-to-date topic.
Collapse
|
6
|
Circulating Sphingosine-1-Phosphate as A Non-Invasive Biomarker of Heart Transplant Rejection. Sci Rep 2019; 9:13880. [PMID: 31554869 PMCID: PMC6761203 DOI: 10.1038/s41598-019-50413-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 09/05/2019] [Indexed: 01/16/2023] Open
Abstract
Accumulating evidence has confirmed that the expression of sarcoplasmic reticulum calcium ATPase 2a (SERCA2a) is downregulated in heart failure and cardiac allograft rejection. Although many SERCA2a-related genes and proteins involved in the regulation of myocardial Ca2+ fluxes have been explored, its related metabolites remain poorly studied. Our main objective was to identify circulating SERCA2a-related metabolites altered in cardiac allograft rejection and to determine whether these could serve as non-invasive biomarkers. Sixty plasma samples from adult heart transplant were included in a metabolomic analysis. Sphingosine-1 phosphate (S1P), metabolite closely related with SERCA, were increased in patients with cardiac rejection (p < 0.0001). S1P discriminated between patients with and without rejection: normal grafts vs. all rejecting grafts (AUC = 0.911, p < 0.0001), normal grafts vs. Grade 1 R (AUC = 0.819, p < 0.01), Grade 2 R (AUC = 0.911, p < 0.0001), Grade 3 R (AUC = 0.996, p < 0.0001). In addition, we found changes in key enzymes and receptors of S1P pathway analysed on explanted hearts from heart failure patients. This preliminary study reveals that circulating S1P determination could be a novel approach to detect cardiac rejection, showing a robust capability for detection that improves gradually with the severity of rejection. These alterations could be relevant to better understand the involvement of calcium regulation on the pathophysiology of rejection.
Collapse
|
7
|
Biomarkers to Assess Right Heart Pressures in Recipients of a Heart Transplant: A Proof-of-Concept Study. Transplant Direct 2018; 4:e346. [PMID: 29796417 PMCID: PMC5959348 DOI: 10.1097/txd.0000000000000783] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 01/31/2018] [Indexed: 11/26/2022] Open
Abstract
Background This proof-of-concept study investigated the feasibility of using biomarkers to monitor right heart pressures (RHP) in heart transplanted (HTx) patients. Methods In 298 patients, we measured 7.6 years post-HTx mean pressures in the right atrium (mRAP) and pulmonary artery (mPAP) and capillaries (mPCWP) along with plasma high-sensitivity troponin T (hsTnT), a marker of cardiomyocyte injury, and the multidimensional urinary classifiers HF1 and HF2, mainly consisting of dysregulated collagen fragments. Results In multivariable models, mRAP and mPAP increased with hsTnT (per 1-SD, +0.91 and +1.26 mm Hg; P < 0.0001) and with HF2 (+0.42 and +0.62 mm Hg; P ≤ 0.035), but not with HF1. mPCWP increased with hsTnT (+1.16 mm Hg; P < 0.0001), but not with HF1 or HF2. The adjusted odds ratios for having elevated RHP (mRAP, mPAP or mPCWP ≥10, ≥24, ≥17 mm Hg, respectively) were 1.99 for hsTnT and 1.56 for HF2 (P ≤ 0.005). In detecting elevated RHPs, areas under the curve were similar for hsTnT and HF2 (0.63 vs 0.65; P = 0.66). Adding hsTnT continuous or per threshold or HF2 continuous to a basic model including all covariables did not increase diagnostic accuracy (P ≥ 0.11), whereas adding HF2 per optimized threshold increased both the integrated discrimination (+1.92%; P = 0.023) and net reclassification (+30.3%; P = 0.010) improvement. Conclusions Correlating RHPs with noninvasive biomarkers in HTx patients is feasible. However, further refinement and validation of such biomarkers is required before their clinical application can be considered.
Collapse
|
8
|
Fitzsimons S, Evans J, Parameshwar J, Pettit SJ. Utility of troponin assays for exclusion of acute cellular rejection after heart transplantation: A systematic review. J Heart Lung Transplant 2017; 37:631-638. [PMID: 29426716 DOI: 10.1016/j.healun.2017.12.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 11/06/2017] [Accepted: 12/05/2017] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Acute cellular rejection (ACR) is a common complication in the first year after heart transplantation (HT). Routine surveillance for ACR is undertaken by endomyocardial biopsy (EMB). Measurement of cardiac troponins (cTn) in serum is an established diagnostic test of cardiac myocyte injury. This systematic review aimed to determine whether cTn measurement could be used to diagnose or exclude ACR. METHODS PubMed, Google Scholar and the JHLT archive were searched for studies reporting the result of a cTn assay and a paired surveillance EMB. Significant ACR was defined as International Society for Heart and Lung Transplantataion (ISHLT) Grade ≥3a/≥2R. Considerable heterogeneity between studies precluded quantitative meta-analysis. Individual study sensitivity and specificity data were examined and used to construct a pooled hierarchical summary receiver-operator characteristic (ROC) curve. RESULTS Twelve studies including 993 patients and 3,803 EMBs, of which 3,729 were paired with cTn levels, had adequate data available for inclusion. The overall rate of significant ACR was 12%. There was wide variation in diagnostic performance. cTn assays demonstrated sensitivity of 8% to 100% and specificity of 13% to 88% for detection of ACR. The positive predictive value (PPV) was low but the negative predictive value (NPV) was relatively high (79% to 100%). High-sensitivity cTn assays had greater sensitivity and NPV than conventional cTn assays for detection of ACR (sensitivity: 82% to 100% vs 8% to 77%; NPV: 97% to 100% vs 81% to 95%, respectively). CONCLUSIONS cTn assays do not have sufficient specificity to diagnose ACR in place of EMB. However, hs-cTn assays may have sufficient sensitivity and negative predictive value to exclude ACR and limit the need for surveillance EMB. Further research is required to assess this strategy.
Collapse
Affiliation(s)
- Sarah Fitzsimons
- Transplant Unit, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge, UK; Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK.
| | - Jonathan Evans
- Transplant Unit, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge, UK; Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Jayan Parameshwar
- Transplant Unit, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge, UK; Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Stephen J Pettit
- Transplant Unit, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge, UK; Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| |
Collapse
|
9
|
SERCA2a: A potential non-invasive biomarker of cardiac allograft rejection. J Heart Lung Transplant 2017; 36:1322-1328. [PMID: 28750934 DOI: 10.1016/j.healun.2017.07.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 06/15/2017] [Accepted: 07/03/2017] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND The detection of heart transplant rejection by non-invasive methods remains a major challenge. Despite the well-known importance of the study of sarcoplasmic reticulum Ca2+-ATPase (SERCA2a) in the heart, its role as a rejection marker has never been analyzed. Our objective in this study was to determine whether circulating SERCA2a could be a good marker of cardiac rejection. METHODS We collected 127 consecutive endomyocardial biopsies (EMBs) and serum samples from adult heart transplant recipients (49 without allograft rejection and 78 with the diagnosis of biopsy allograft rejection, including 48 Grade 1R, 21 Grade 2R and 9 Grade 3R). Serum concentrations of SERCA2a were determined using a specific sandwich enzyme-linked immunosorbent assay. We also analyzed SERCA2a expression changes on EMBs using immunofluorescence. RESULTS SERCA2a cardiac tissue and serum levels were decreased in patients with cardiac rejection (p < 0.0001). A receiver-operating characteristic analysis showed that SERCA2a strongly discriminated between patients with and without allograft rejection: normal grafts vs all rejecting grafts (AUC = 0.804); normal grafts vs Grade 1R (AUC = 0.751); normal grafts vs Grade 2R (AUC = 0.875); normal grafts vs Grade 3R (AUC = 0.922); normal grafts vs Grade 2R and 3R (AUC = 0.889), with p < 0.0001 for all comparisons. CONCLUSIONS We demonstrated that changes in SERCA2a cardiac tissue and serum levels occur in cardiac allograft rejection. Our findings suggest that SERCA2a concentration assessment may be a relatively simple, non-invasive test for heart transplant rejection, showing a strong capability for detection that improves progressively as rejection grades increase.
Collapse
|
10
|
Abstract
Despite major advances in the medical care of patients following heart transplantation (HTx) and a steady increase in long-term survival, allograft surveillance is still based on endomyocardial biopsy, the gold standard since the 1970s. This invasive procedure calls for less burdening and more cost-effective approaches. In recent years, impressive progress has been made in utilizing blood-based biomarkers for the diagnosis and management of diseases in a variety of fields. Hence, a number of trials have been performed testing the usefulness of circulating molecules or other technical methods to overcome the need for surveillance myocardial biopsy in HTx patients. Here, we review current approaches and the state of research on novel biomarkers for the management of patients following heart transplantation.
Collapse
|
11
|
Ojaghi Haghighi Z, Amin A, Chitsazan M, Taghavi S, Naderi N, Abdollahi M, Mozaffari K. Evaluation of the Role of Conventional and Tissue Doppler Imaging Echocardiography in Detection of Acute Cardiac Allograft Rejection in Heart Transplant Recipients. Int Cardiovasc Res J 2016. [DOI: 10.17795/icrj-10(1)35] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
|
12
|
Ahn KT, Choi JO, Lee GY, Park HD, Jeon ES. Usefulness of high-sensitivity troponin I for the monitoring of subclinical acute cellular rejection after cardiac transplantation. Transplant Proc 2015; 47:504-10. [PMID: 25769598 DOI: 10.1016/j.transproceed.2014.10.049] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Revised: 10/15/2014] [Accepted: 10/28/2014] [Indexed: 11/25/2022]
Abstract
BACKGROUND There are conflicting data about the role of cardiac troponin I (cTnI) as determined by means of conventional methods for the prediction of acute rejection after heart transplantation (HT). The purpose of this study was to evaluate whether cTnI as measured by means of the early prototype high-sensitivity assay (hs-cTnI) can predict acute rejection episode after HT compared with grade of rejection in endomyocardial biopsy (EMB). METHODS This was a single-center cross-sectional study evaluating cTnI levels with the use of both hs-cTnI and current less sensitive conventional cTnI (conv-cTnI) assays measured at the time of EMB after HT. We calculated an index ratio of observed cTnI to expected mean cTnI for each individual patient defined as the mean cTnI measurements at EMB 60 days after HT. RESULTS A total of 252 biopsies from 47 patients were included in this study. In the multivariable mixed model analysis in relation to the presence of acute rejection 60 days after HT, hs-cTnI level was significantly related to the presence of rejection (P = .010). The hs-cTnI ratio index was significantly higher at the time of rejection (median, 1.37; interquartile range [IQR], 1.23-2.88) compared with those without rejection (median, 0.90; IQR, 0.51-1.16; P < .001). In receiver operating characteristic curve analysis, an hs-cTnI ratio index of ≥1.17 could predict the acute rejection with a sensitivity of 82.4% and a specificity of 77.1%. CONCLUSIONS An increased hs-cTnI ratio index was significantly related to rejection episodes. Serial monitoring of hs-cTnI and comparing it with the values without rejection might be useful for the detection of acute rejection after HT.
Collapse
Affiliation(s)
- K T Ahn
- Division of Cardiology, Cardiac and Vascular Centers, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - J-O Choi
- Division of Cardiology, Cardiac and Vascular Centers, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - G Y Lee
- Division of Cardiology, Cardiac and Vascular Centers, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - H-D Park
- Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - E-S Jeon
- Division of Cardiology, Cardiac and Vascular Centers, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
| |
Collapse
|
13
|
McMinn JF, Lang NN, McPhadden A, Payne JR, Petrie MC, Gardner RS. Biomarkers of acute rejection following cardiac transplantation. Biomark Med 2015; 8:815-32. [PMID: 25224938 DOI: 10.2217/bmm.14.56] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Cardiac transplantation can be a life-saving treatment for selected patients with heart failure. However, despite advances in immunosuppressive therapy, acute allograft rejection remains a significant cause of morbidity and mortality. The current 'gold standard' for rejection surveillance is endomyocardial biopsy, which aims to identify episodes of rejection prior to development of clinical manifestations. This is an invasive technique with a risk of false-positive and false-negative results. Consequently, a wide variety of noninvasive alternatives have been investigated for their potential role as biomarkers of rejection. This article reviews the evidence behind proposed alternatives such as imaging techniques, electrophysiological parameters and peripheral blood markers, and highlights the potential future role for biomarkers in cardiac transplantation as an adjunct to biopsy.
Collapse
Affiliation(s)
- Jenna F McMinn
- Scottish National Advanced Heart Failure Service, Golden Jubilee National Hospital, Clydebank, UK
| | | | | | | | | | | |
Collapse
|
14
|
Repeated measurements of NT-pro-B-type natriuretic peptide, troponin T or C-reactive protein do not predict future allograft rejection in heart transplant recipients. Transplantation 2015; 99:580-5. [PMID: 25136844 DOI: 10.1097/tp.0000000000000378] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Studies on the prognostic value of serial biomarker assays for future occurrence of allograft rejection (AR) are scarce. We examined whether repeated measurements of NT-pro-B-type natriuretic peptide (NT-proBNP), troponin T (TropT) and C-reactive protein (CRP) predict AR. METHODS From 2005 to 2010, 77 consecutive heart transplantation (HTx) recipients were included. The NT-proBNP, TropT, and CRP were measured at 16 ± 4 (mean ± standard deviation) consecutive routine endomyocardial biopsy surveillance visits during the first year of follow-up. Allograft rejection was defined as International Society for Heart and Lung Transplantation (ISHLT) grade 2R or higher at endomyocardial biopsy. Joint modeling was used to assess the association between repeated biomarker measurements and occurrence of future AR. Joint modeling accounts for dependence among repeated observations in individual patients. RESULTS The mean age of the patients at HTx was 49 ± 9.2 years, and 68% were men. During the first year of follow-up, 1,136 biopsies and concurrent blood samples were obtained, and 56 patients (73%) experienced at least one episode of AR. All biomarkers were elevated directly after HTx and achieved steady-state after ∼ 12 weeks, both in patients with or without AR. No associations were present between the repeated measurements of NT-proBNP, TropT, or CRP and AR both early (weeks 0-12) and late (weeks 13-52) in the course after HTx (hazard ratios for weeks 13-52: 0.96 (95% confidence interval, 0.55-1.68), 0.67 (0.27-1.69), and 1.44 (0.90-2.30), respectively, per ln[unit]). Combining the three biomarkers in one model also rendered null results. CONCLUSION The temporal evolution of NT-proBNP, TropT, and CRP before AR did not predict occurrence of acute AR both in the early and late course of the first year after HTx.
Collapse
|
15
|
Katz JN, Waters SB, Hollis IB, Chang PP. Advanced therapies for end-stage heart failure. Curr Cardiol Rev 2015; 11:63-72. [PMID: 24251460 PMCID: PMC4347211 DOI: 10.2174/1573403x09666131117163825] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2013] [Revised: 06/09/2013] [Accepted: 09/27/2013] [Indexed: 11/22/2022] Open
Abstract
Management of the advanced heart failure patient can be complex. Therapies include cardiac transplantation and mechanical circulatory support, as well inotropic agents for the short-term. Despite a growing armamentarium of resources, the clinician must carefully weigh the risks and benefits of each therapy to develop an optimal treatment strategy. While cardiac transplantation remains the only true “cure” for end-stage disease, this resource is limited and the demand continues to far outpace the supply. For patients who are transplant-ineligible or likely to succumb to their illness prior to transplant, ventricular assist device therapy has now become a viable option for improving morbidity and mortality. Particularly for the non-operative pa-tient, intravenous inotropes can be utilized for symptom control. Regardless of the treatments considered, care of the heart failure patient requires thoughtful dialogue, multidisciplinary collaboration, and individualized care. While survival is important, most patients covet quality of life above all outcomes. An often overlooked component is the patient’s control over the dying process. It is vital that clinicians make goals-of-care discussions a priority when seeing patients with advanced heart failure. The use of palliative care consultation is well-validated and facilitates these difficult conversations to ensure that all patient needs are ultimately met.
Collapse
Affiliation(s)
| | | | | | - Patricia P Chang
- Division of Pulmonary & Critical Care Medicine, 160 Dental Circle, CB#7075, Burnett-Womack Building, 6th Floor, Chapel Hill, NC 27599-7075, USA.
| |
Collapse
|
16
|
Patel PC, Hill DA, Ayers CR, Lavingia B, Kaiser P, Dyer AK, Barnes AP, Thibodeau JT, Mishkin JD, Mammen PPA, Markham DW, Stastny P, Ring WS, de Lemos JA, Drazner MH. High-sensitivity cardiac troponin I assay to screen for acute rejection in patients with heart transplant. Circ Heart Fail 2014; 7:463-9. [PMID: 24733367 DOI: 10.1161/circheartfailure.113.000697] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND A noninvasive biomarker that could accurately diagnose acute rejection (AR) in heart transplant recipients could obviate the need for surveillance endomyocardial biopsies. We assessed the performance metrics of a novel high-sensitivity cardiac troponin I (cTnI) assay for this purpose. METHODS AND RESULTS Stored serum samples were retrospectively matched to endomyocardial biopsies in 98 cardiac transplant recipients, who survived ≥3 months after transplant. AR was defined as International Society for Heart and Lung Transplantation grade 2R or higher cellular rejection, acellular rejection, or allograft dysfunction of uncertain pathogenesis, leading to treatment for presumed rejection. cTnI was measured with a high-sensitivity assay (Abbott Diagnostics, Abbott Park, IL). Cross-sectional analyses determined the association of cTnI concentrations with rejection and International Society for Heart and Lung Transplantation grade and the performance metrics of cTnI for the detection of AR. Among 98 subjects, 37% had ≥1 rejection episode. cTnI was measured in 418 serum samples, including 35 paired to a rejection episode. cTnI concentrations were significantly higher in rejection versus nonrejection samples (median, 57.1 versus 10.2 ng/L; P<0.0001) and increased in a graded manner with higher biopsy scores (P(trend)<0.0001). The c-statistic to discriminate AR was 0.82 (95% confidence interval, 0.76-0.88). Using a cut point of 15 ng/L, sensitivity was 94%, specificity 60%, positive predictive value 18%, and negative predictive value 99%. CONCLUSIONS A high-sensitivity cTnI assay seems useful to rule out AR in cardiac transplant recipients. If validated in prospective studies, a strategy of serial monitoring with a high-sensitivity cTnI assay may offer a low-cost noninvasive strategy for rejection surveillance.
Collapse
Affiliation(s)
- Parag C Patel
- From the Department of Transplant, Mayo Clinic Florida, Jacksonville (P.C.P.); and Department of Internal Medicine, Division of Cardiology (D.A.H., C.R.A., P.K., J.T.T., J.D.M., P.P.A.M., D.W.M., J.A.d.L., M.H.D.), Department of Internal Medicine, Division of Transplant Immunology (B.L., P.S.), Department of Pediatrics, Division of Pediatric Cardiology (A.K.D., A.P.B.), and Department of Cardiothoracic Surgery (W.S.R.), University of Texas Southwestern Medical Center, Dallas
| | - Douglas A Hill
- From the Department of Transplant, Mayo Clinic Florida, Jacksonville (P.C.P.); and Department of Internal Medicine, Division of Cardiology (D.A.H., C.R.A., P.K., J.T.T., J.D.M., P.P.A.M., D.W.M., J.A.d.L., M.H.D.), Department of Internal Medicine, Division of Transplant Immunology (B.L., P.S.), Department of Pediatrics, Division of Pediatric Cardiology (A.K.D., A.P.B.), and Department of Cardiothoracic Surgery (W.S.R.), University of Texas Southwestern Medical Center, Dallas
| | - Colby R Ayers
- From the Department of Transplant, Mayo Clinic Florida, Jacksonville (P.C.P.); and Department of Internal Medicine, Division of Cardiology (D.A.H., C.R.A., P.K., J.T.T., J.D.M., P.P.A.M., D.W.M., J.A.d.L., M.H.D.), Department of Internal Medicine, Division of Transplant Immunology (B.L., P.S.), Department of Pediatrics, Division of Pediatric Cardiology (A.K.D., A.P.B.), and Department of Cardiothoracic Surgery (W.S.R.), University of Texas Southwestern Medical Center, Dallas
| | - Bhavna Lavingia
- From the Department of Transplant, Mayo Clinic Florida, Jacksonville (P.C.P.); and Department of Internal Medicine, Division of Cardiology (D.A.H., C.R.A., P.K., J.T.T., J.D.M., P.P.A.M., D.W.M., J.A.d.L., M.H.D.), Department of Internal Medicine, Division of Transplant Immunology (B.L., P.S.), Department of Pediatrics, Division of Pediatric Cardiology (A.K.D., A.P.B.), and Department of Cardiothoracic Surgery (W.S.R.), University of Texas Southwestern Medical Center, Dallas
| | - Patricia Kaiser
- From the Department of Transplant, Mayo Clinic Florida, Jacksonville (P.C.P.); and Department of Internal Medicine, Division of Cardiology (D.A.H., C.R.A., P.K., J.T.T., J.D.M., P.P.A.M., D.W.M., J.A.d.L., M.H.D.), Department of Internal Medicine, Division of Transplant Immunology (B.L., P.S.), Department of Pediatrics, Division of Pediatric Cardiology (A.K.D., A.P.B.), and Department of Cardiothoracic Surgery (W.S.R.), University of Texas Southwestern Medical Center, Dallas
| | - Adrian K Dyer
- From the Department of Transplant, Mayo Clinic Florida, Jacksonville (P.C.P.); and Department of Internal Medicine, Division of Cardiology (D.A.H., C.R.A., P.K., J.T.T., J.D.M., P.P.A.M., D.W.M., J.A.d.L., M.H.D.), Department of Internal Medicine, Division of Transplant Immunology (B.L., P.S.), Department of Pediatrics, Division of Pediatric Cardiology (A.K.D., A.P.B.), and Department of Cardiothoracic Surgery (W.S.R.), University of Texas Southwestern Medical Center, Dallas
| | - Aliessa P Barnes
- From the Department of Transplant, Mayo Clinic Florida, Jacksonville (P.C.P.); and Department of Internal Medicine, Division of Cardiology (D.A.H., C.R.A., P.K., J.T.T., J.D.M., P.P.A.M., D.W.M., J.A.d.L., M.H.D.), Department of Internal Medicine, Division of Transplant Immunology (B.L., P.S.), Department of Pediatrics, Division of Pediatric Cardiology (A.K.D., A.P.B.), and Department of Cardiothoracic Surgery (W.S.R.), University of Texas Southwestern Medical Center, Dallas
| | - Jennifer T Thibodeau
- From the Department of Transplant, Mayo Clinic Florida, Jacksonville (P.C.P.); and Department of Internal Medicine, Division of Cardiology (D.A.H., C.R.A., P.K., J.T.T., J.D.M., P.P.A.M., D.W.M., J.A.d.L., M.H.D.), Department of Internal Medicine, Division of Transplant Immunology (B.L., P.S.), Department of Pediatrics, Division of Pediatric Cardiology (A.K.D., A.P.B.), and Department of Cardiothoracic Surgery (W.S.R.), University of Texas Southwestern Medical Center, Dallas
| | - Joseph D Mishkin
- From the Department of Transplant, Mayo Clinic Florida, Jacksonville (P.C.P.); and Department of Internal Medicine, Division of Cardiology (D.A.H., C.R.A., P.K., J.T.T., J.D.M., P.P.A.M., D.W.M., J.A.d.L., M.H.D.), Department of Internal Medicine, Division of Transplant Immunology (B.L., P.S.), Department of Pediatrics, Division of Pediatric Cardiology (A.K.D., A.P.B.), and Department of Cardiothoracic Surgery (W.S.R.), University of Texas Southwestern Medical Center, Dallas
| | - Pradeep P A Mammen
- From the Department of Transplant, Mayo Clinic Florida, Jacksonville (P.C.P.); and Department of Internal Medicine, Division of Cardiology (D.A.H., C.R.A., P.K., J.T.T., J.D.M., P.P.A.M., D.W.M., J.A.d.L., M.H.D.), Department of Internal Medicine, Division of Transplant Immunology (B.L., P.S.), Department of Pediatrics, Division of Pediatric Cardiology (A.K.D., A.P.B.), and Department of Cardiothoracic Surgery (W.S.R.), University of Texas Southwestern Medical Center, Dallas
| | - David W Markham
- From the Department of Transplant, Mayo Clinic Florida, Jacksonville (P.C.P.); and Department of Internal Medicine, Division of Cardiology (D.A.H., C.R.A., P.K., J.T.T., J.D.M., P.P.A.M., D.W.M., J.A.d.L., M.H.D.), Department of Internal Medicine, Division of Transplant Immunology (B.L., P.S.), Department of Pediatrics, Division of Pediatric Cardiology (A.K.D., A.P.B.), and Department of Cardiothoracic Surgery (W.S.R.), University of Texas Southwestern Medical Center, Dallas
| | - Peter Stastny
- From the Department of Transplant, Mayo Clinic Florida, Jacksonville (P.C.P.); and Department of Internal Medicine, Division of Cardiology (D.A.H., C.R.A., P.K., J.T.T., J.D.M., P.P.A.M., D.W.M., J.A.d.L., M.H.D.), Department of Internal Medicine, Division of Transplant Immunology (B.L., P.S.), Department of Pediatrics, Division of Pediatric Cardiology (A.K.D., A.P.B.), and Department of Cardiothoracic Surgery (W.S.R.), University of Texas Southwestern Medical Center, Dallas
| | - W Steves Ring
- From the Department of Transplant, Mayo Clinic Florida, Jacksonville (P.C.P.); and Department of Internal Medicine, Division of Cardiology (D.A.H., C.R.A., P.K., J.T.T., J.D.M., P.P.A.M., D.W.M., J.A.d.L., M.H.D.), Department of Internal Medicine, Division of Transplant Immunology (B.L., P.S.), Department of Pediatrics, Division of Pediatric Cardiology (A.K.D., A.P.B.), and Department of Cardiothoracic Surgery (W.S.R.), University of Texas Southwestern Medical Center, Dallas
| | - James A de Lemos
- From the Department of Transplant, Mayo Clinic Florida, Jacksonville (P.C.P.); and Department of Internal Medicine, Division of Cardiology (D.A.H., C.R.A., P.K., J.T.T., J.D.M., P.P.A.M., D.W.M., J.A.d.L., M.H.D.), Department of Internal Medicine, Division of Transplant Immunology (B.L., P.S.), Department of Pediatrics, Division of Pediatric Cardiology (A.K.D., A.P.B.), and Department of Cardiothoracic Surgery (W.S.R.), University of Texas Southwestern Medical Center, Dallas.
| | - Mark H Drazner
- From the Department of Transplant, Mayo Clinic Florida, Jacksonville (P.C.P.); and Department of Internal Medicine, Division of Cardiology (D.A.H., C.R.A., P.K., J.T.T., J.D.M., P.P.A.M., D.W.M., J.A.d.L., M.H.D.), Department of Internal Medicine, Division of Transplant Immunology (B.L., P.S.), Department of Pediatrics, Division of Pediatric Cardiology (A.K.D., A.P.B.), and Department of Cardiothoracic Surgery (W.S.R.), University of Texas Southwestern Medical Center, Dallas.
| |
Collapse
|
17
|
Do established biomarkers such as B-type natriuretic peptide and troponin predict rejection? Curr Opin Organ Transplant 2013; 18:581-8. [DOI: 10.1097/mot.0b013e328364fe23] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
18
|
ACCF 2012 expert consensus document on practical clinical considerations in the interpretation of troponin elevations: a report of the American College of Cardiology Foundation task force on Clinical Expert Consensus Documents. J Am Coll Cardiol 2012; 60:2427-63. [PMID: 23154053 DOI: 10.1016/j.jacc.2012.08.969] [Citation(s) in RCA: 263] [Impact Index Per Article: 21.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
|
19
|
Dyer AK, Barnes AP, Fixler DE, Shah TK, Sutcliffe DL, Hashim I, Drazner MH, de Lemos JA. Use of a highly sensitive assay for cardiac troponin T and N-terminal pro-brain natriuretic peptide to diagnose acute rejection in pediatric cardiac transplant recipients. Am Heart J 2012; 163:595-600. [PMID: 22520525 DOI: 10.1016/j.ahj.2012.02.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2012] [Accepted: 02/01/2012] [Indexed: 11/29/2022]
Abstract
BACKGROUND Biomarkers have been proposed to augment or replace endomyocardial biopsy (EMB) to diagnose acute transplant rejection (AR). A new, highly sensitive assay for troponin T detects levels of cardiac troponin T (cTnT) 10- to 100-fold lower than standard assays but has not been investigated in transplant patients. N-terminal pro-brain natriuretic peptide (NT-proBNP) has not been evaluated in pediatric transplant patients. The purpose of this pilot study was to evaluate the association of cTnT and NT-proBNP with AR in pediatric cardiac transplant patients. METHODS Plasma was obtained at the time of EMB from pediatric patients ≥ 1 year old. N-terminal pro-brain natriuretic peptide was measured in fresh plasma at the time of biopsy, and cTnT was measured from frozen, stored samples using the highly sensitive assay for troponin T. Biomarker data were correlated with EMB results. Cellular AR was defined as an International Society for Heart and Lung Transplantation biopsy score of grade ≥ 2R. RESULTS Fifty-three blood samples were obtained from 42 patients (mean age 11 years). Seven episodes of AR occurred in 5 patients. Biopsies with vs without AR were associated with higher cTnT (median [interquartile range {IQR}] 66 [45-139] vs 7 [2-13] pg/mL, P = .001) and NT-proBNP (median [IQR] 11,169 [280-23,317] vs 334 [160-650] pg/mL, P < .01). After successful treatment of AR in 5 patients, cTnT fell markedly (median [IQR] 53.5 [44.8-66.5] to 10.7 [1.5-16.4], P = .05). CONCLUSION In this pilot study, we found marked elevation of cTnT and NT-proBNP among children with AR. Moreover, reduction in cTnT levels after treatment paralleled improvement in EMB results. If these findings are confirmed in larger prospective studies, monitoring with these biomarkers may obviate surveillance EMB.
Collapse
Affiliation(s)
- Adrian K Dyer
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX 75390-9047, USA
| | | | | | | | | | | | | | | |
Collapse
|
20
|
[Usefulness of high sensitivity troponin T assay in detecting acute allograft rejection after heart transplantation]. Rev Esp Cardiol 2011; 64:1109-13. [PMID: 21924812 DOI: 10.1016/j.recesp.2011.06.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2011] [Accepted: 06/19/2011] [Indexed: 11/22/2022]
Abstract
INTRODUCTION AND OBJECTIVES Detection of acute allograft rejection in heart transplant recipients by noninvasive methods is a challenge in the management of these patients. In this study, the usefulness of a new highly sensitive method for the measurement of troponin T is evaluated. METHODS We designed a case-crossover study, in which each patient served as his or her own control, by selecting samples from treated acute rejection episodes (29 cases) and samples obtained immediately before and/or after rejection (38 controls). The highly sensitive troponin T was measured by a new pre-commercial test (Elecsys Troponin T HS). RESULTS In all samples, highly sensitive troponin T was detectable, with a median of 0.068 ng/L (IQR, 0.030-0.300 ng/L). The levels correlated with right atrial pressure (r=0.37; P=.002), N-terminal pro-brain natriuretic peptide concentration (r=0.67; P<.001), and time since transplantation (r=-0.81; P<.001). The highly sensitive troponin T concentrations were higher in patients with rejection (0.155 ng/mL vs 0.047 ng/mL; P=.006). In the receiver operating characteristic analysis, the area under the curve was 0.67 (95% confidence interval, 0.53-0.77) and the best cutoff was 0.035 ng/mL, which was associated with rejection (odds ratio=3.7; 95% confidence interval, 1.2-11.9; P=.02). By restricting the analysis to the first 2 months, the area under the curve increased to 0.86 (95% confidence interval 0.66-0.97), with an optimal cutoff of 1.10 ng/mL (S=58% [28%-85%]; E=100% [74%-100%]). CONCLUSIONS Troponin T was detectable in all samples when a new highly sensitive assay was used, and at higher concentrations in the presence of acute rejection; however, the usefulness of this test in patient management is limited to support for clinical or histological suspicion of rejection, especially in the early post-transplant period.
Collapse
|
21
|
Frick M, Antretter H, Pachinger O, Pölzl G. Biomarker zur Diagnose der zellulären Abstoßung nach Herztransplantation. Herz 2010; 35:11-6. [DOI: 10.1007/s00059-010-3309-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
22
|
Godet G, Bernard M, Ben Ayed S. [Cardiac biomarkers for diagnosis of myocardial infarction]. ACTA ACUST UNITED AC 2009; 28:321-31. [PMID: 19304448 DOI: 10.1016/j.annfar.2009.01.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2008] [Accepted: 01/14/2009] [Indexed: 11/29/2022]
Abstract
Diagnosis of postoperative myocardial infarction is often difficult, based on tools with a low sensitivity (clinical symptoms, EKG), or with a low specifity (old biomarkers, echocardiographic abnormalities) or inadequate for clinical practice (scintigraphy). Since 1995, clinicians may use more cardiospecific markers (troponin) allowing to modify strategy for postoperative myocardial infarction diagnosis. The aim of this review is to resume such an attitude.
Collapse
Affiliation(s)
- G Godet
- Département d'anesthésie et réanimation 2, hôpital Pontchaillou, 2, rue Henri-Le-Guilloux, 35033 Rennes cedex, France.
| | | | | |
Collapse
|
23
|
McLaren BK, Venkatesh PK, Misra P, Zhang PL, Fowler MR. Increased Expression of p53 Protein Correlates With the Extent of Myocyte Damage in Cardiac Allograft Rejection. ACTA ACUST UNITED AC 2008; 14:293-7. [DOI: 10.1111/j.1751-7133.2008.00018.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
24
|
Bañón-Maneus E, Kahbiri E, Marín JL, Pomar-Moya JL, Ramírez J, Climent F, de la Ossa PP. Increased serum creatine kinase is a reliable marker for acute transplanted heart rejection diagnosis in rats. Transpl Int 2007; 20:184-9. [PMID: 17239027 DOI: 10.1111/j.1432-2277.2006.00410.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Different molecules have been studied as biochemical markers in heart transplantation. However, their utility is under discussion as results in human and animal models are controversial. In this work, lactate dehydrogenase (LDH), creatine kinase (CK) and cardiac troponin I (TnI) were studied as serologic markers of acute rejection after heterotopical heart transplantation in rats. In predictable rejection experiments, animals were divided into three groups: nonoperated (Lewis rats), control group (Lewis-Lewis isografts) and rejection group (Brown Norway-Lewis allografts). Nonpredictable rejection experiments were performed using nonconsanguineous Sprague-Dawley allografts. In predictable rejection experiments, LDH activity was similar between control and rejection groups. TnI values were heterogeneous in control and rejection groups. In contrast, the rejection group showed CK activity increased 4.5-fold compared with the control group. In addition to these predictable studies, we also presented novel nonpredictable experiments in which rats were divided into groups based on low and high CK activity. Histologic studies in these rats showed that none of those with low CK activity presented rejection signs, while all animals with high CK levels showed grade 2R rejection. These results suggest that CK might be an excellent marker for prediction of rejection in heart transplantation.
Collapse
Affiliation(s)
- Elisenda Bañón-Maneus
- Departament de Ciéncies Fisiològiques I, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Unitat de Bioquímica, Facultat de Medicina, Universitat de Barcelona, and Departament de Cirurgia i Especialitats Quirúrgiques, Hospital Clinic, Spain
| | | | | | | | | | | | | |
Collapse
|
25
|
Dengler TJ, Gleissner CA, Klingenberg R, Sack FU, Schnabel PA, Katus HA. Biomarkers After Heart Transplantation: Nongenomic. Heart Fail Clin 2007; 3:69-81. [DOI: 10.1016/j.hfc.2007.02.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
|
26
|
NT-proBNP as a non-invasive marker of acute rejection in heart transplant recipients. COR ET VASA 2006. [DOI: 10.33678/cor.2006.125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|
27
|
Berroëta C, Provenchère S, Mongredien A, Lasocki S, Benessiano J, Dehoux M, Philip I. Dosage des isoformes cardiaques des troponines T ou I : intérêt en cardiologie et en anesthésie–réanimation. ACTA ACUST UNITED AC 2006; 25:1053-63. [PMID: 16019183 DOI: 10.1016/j.annfar.2005.05.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2004] [Accepted: 05/09/2005] [Indexed: 01/08/2023]
Abstract
Measurement of cardiac troponin I or T in serum (highly specific for the myocardium) have replaced classical markers, such as creatine kinase MB. Cardiac troponins are preferred markers because of their high specificity and sensitivity. This had led to modifications of the original World Health Organization criteria for acute myocardial infarction. Furthermore, the place of the troponins as superior markers of subsequent cardiac risk in acute coronary syndrome has now become firmly established, for both diagnostic and risk stratification purposes. The use of C-reactive protein and/or other inflammatory biomarkers may add independent information in this context. After non cardiac surgery, the total cardiospecificity of cardiac troponins explains why other biomarkers of necrosis should no longer be used. Recent studies suggest that any elevation of troponin in the postoperative period is indicative of increased risk of long-term cardiac complications. This prognostic value has been previously demonstrated in other clinical settings such as invasive coronary intervention (surgical myocardial revascularization and percutaneous coronary intervention) and after heart valve surgery. Increases of troponin indicate cardiac damage, whatever the mechanism (ischemic or not). Other causes of cardiac injury include: pulmonary embolism, myocarditis, pericarditis, congestive heart failure, septic shock, myocardial contusion. In most cases, elevation of troponins has been shown to be associated with a bad outcome.
Collapse
Affiliation(s)
- C Berroëta
- Département d'anesthésie-réanimation, hôpital Bichat-Claude-Bernard, Assistance publique-Hôpitaux de Paris, 48 rue Henri-Huchard, 75018 Paris, France
| | | | | | | | | | | | | |
Collapse
|
28
|
Moresco RN, Vargas LCR, Júnior RH, da Rocha Silla LM. Lack of association between cardiac troponin T and D-dimer in the evaluation of myocardial damage. J Clin Lab Anal 2006; 19:282-4. [PMID: 16302207 PMCID: PMC6808126 DOI: 10.1002/jcla.20082] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Acute myocardial infarction (AMI) disrupts cardiac cell membranes, releasing intracellular cardiac proteins into the vascular system. Some of these proteins, including the cardiac troponin subunits T and I, have proven useful for diagnosing myocardial damage. Intracoronary thrombosis plays a key role in the pathogenesis of AMI, and the formation of an occlusive thrombus usually precedes the development of myocardial damage. To evaluate whether there is an association between the size of intracoronary thrombosis and myocardial damage, we analyzed D-dimer and cTnT levels in blood samples from patients suspected to have myocardial damage. We investigated 102 patients who were admitted to emergency service for suspected myocardial damage. D-dimer was assessed with the use of the immunoassay Liatest D-dimer, and cTnT levels were measured with an electrochemiluminescence immunoassay (Troponin T STAT). D-dimer levels were lower in patients with cTnT < 0.01 than in patients presenting cTnT > 0.01 ng/mL. We investigated the relationship between D-dimer and cTnT levels in the patients with cTnT > 0.01 ng/mL (0.40 +/- 0.10 ng/mL), and no significant agreement (r = 0.20, P > 0.05) was observed. The levels of D-dimer were not associated with the levels of cTnT in patients with cTnT > 0.01 ng/mL.
Collapse
Affiliation(s)
- Rafael Noal Moresco
- Serviço de Hematologia Clínica e Transplante de Medula Ossea, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Brazil.
| | | | | | | |
Collapse
|
29
|
Gilman G, Hansen WH, Hagen ME, Rosales AG, Bailey KR, McGregor CGA, Belohlavek M. An Echocardiographic Left Ventricular Wall Area Index for Functional Detection of Myocardial Injury in Hemodynamically Unloaded Hearts. Echocardiography 2006; 23:7-13. [PMID: 16412177 DOI: 10.1111/j.1540-8175.2005.00161.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Functional assessment of the left ventricle is affected by loading conditions. Detection of rejection-mediated myocardial injury in a heterotopic heart transplant model is a challenge for the echocardiographer because the heart is in an unloaded state. We examined the relationship of a novel left ventricular (LV) wall area index (LVWAI) and serum cardiac troponin T (cTnT) levels. The LVWAI, based on prior methods of determining LV mass, was defined as the difference between epicardial and endocardial areas divided by the epicardial area. The biphasic morphometric response of LVWAI reflected changes in the cTnT levels and allowed echocardiographic detection of myocardial injury in hemodynamically unloaded hearts.
Collapse
Affiliation(s)
- Gregory Gilman
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota 55905, USA
| | | | | | | | | | | | | |
Collapse
|
30
|
Ogawa T, Veinot JP, Davies RA, Haddad H, Smith SJ, Masters RG, Hendry PJ, Starling R, de Bold MK, Ponce A, Ma KK, Williams K, de Bold AJ. Neuroendocrine profiling of humans receiving cardiac allografts. J Heart Lung Transplant 2005; 24:1046-54. [PMID: 16102440 DOI: 10.1016/j.healun.2004.06.023] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2004] [Revised: 06/17/2004] [Accepted: 06/19/2004] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Several studies have investigated changes in circulating hormones and markers of cardiac status after heart transplantation in humans. As a result, plasma levels of various hormones and autocoids have been associated with cardiac allograft rejection status. However, no clear associations can be defined given the highly contradictory nature of the available literature. METHODS In this study of 69 consecutive heart transplant patients followed for >2 years we examine the relationship between neurohumors potentially related to allograft rejection and endomyocardial biopsy grade of rejection (according to the ISHLT) and hemodynamic status. Markers assessed include brain natriuretic peptide (BNP), amino-terminal pro-BNP (N-BNP), atrial natriuretic factor (ANF), adrenomedullin, interleukin-1beta, interleukin-6, tumor necrosis factor-alpha, troponin C and C-reactive protein. RESULTS The highest plasma levels for most neurohumors were found shortly after surgery and showed a trend towards normalization with time. BNP and N-BNP were the only significantly elevated plasma analytes for patients with Grade 3 rejection as compared with other ISHLT grades. ANF plasma levels correlated with BNP and N-BNP in Grades 0 to 2, but not in Grade 3, suggesting that in this rejection grade the usual coordinated changes observed in BNP and ANF secretion no longer exist. Cardiac filling pressures were correlated with plasma BNP, N-BNP and ANF levels only for Grades 0 and 1. CONCLUSIONS The timing of blood sampling after transplantation influences the level of the neurohumors measured, which may help explain the conflicting literature reports on the association between neurohumor levels and rejection grade. The significant increase in circulating levels of BNP and N-BNP observed in most cases of Grade 3 rejection occurred with no apparent relationship to post-transplantation time, which suggests a specific influence of acute rejection on BNP gene expression.
Collapse
Affiliation(s)
- Tsuneo Ogawa
- Cardiovascular Endocrinology Laboratory, University of Ottawa Heart Institute, Ontario, Canada
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
31
|
Patel JK, Kobashigawa JA. Immunosuppression, diagnosis, and treatment of cardiac allograft rejection. Semin Thorac Cardiovasc Surg 2004; 16:378-85. [PMID: 15635544 DOI: 10.1053/j.semtcvs.2004.09.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The success of cardiac transplantation has been largely attributable to the development of effective immunosuppressive regimens. The calcineurin inhibitors were pivotal in reducing the frequency of acute rejection and improving early survival. Newer agents, including mycophenolate mofetil and proliferation signal inhibitors, show some promise in further reducing episodes of acute allograft rejection and also having a significant impact on reducing transplant vasculopathy. The role of cytolytic induction therapy remains unclear, although its use may be most appropriate in the high risk presensitized transplant recipient. While the endomyocardial biopsy remains the gold standard for the diagnosis of acute allograft rejection, its invasive nature makes the test suboptimal. The presence of biopsy 'negative' rejection has also led to an appreciation for the role of antibody-mediated rejection in cardiac allograft dysfunction. Effective noninvasive evaluation of allograft rejection remains the ultimate challenge. While imaging technologies have some utility because of their ease of use, more sophisticated techniques such as gene-expession analysis from peripheral blood may show the greatest promise. Management of established acute allograft rejection has significantly improved with our understanding of the immune mechanisms involved. Therapies may be targeted specifically at cellular or humoral components of the immune system.
Collapse
Affiliation(s)
- Jignesh K Patel
- David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA.
| | | |
Collapse
|
32
|
Bryson GL, Chung F, Finegan BA, Friedman Z, Miller DR, van Vlymen J, Cox RG, Crowe MJ, Fuller J, Henderson C. Patient selection in ambulatory anesthesia — An evidence-based review: part I. Can J Anaesth 2004; 51:768-81. [PMID: 15470165 DOI: 10.1007/bf03018449] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE To identify and characterize the evidence supporting decisions made in the care of patients with selected medical conditions undergoing ambulatory anesthesia and surgery. Conditions highlighted in this review include: the elderly, heart transplantation, hyper-reactive airway disease, coronary artery disease, and obstructive sleep apnea. SOURCE A structured search of MEDLINE (1966-2003) was performed using keywords for ambulatory surgery and patient condition. Selected articles were assigned a level of evidence using Centre for Evidence Based Medicine (CEBM) criteria. Recommendations were also graded using CEBM criteria. PRINCIPAL FINDINGS The elderly may safely undergo ambulatory surgery but are at increased risk for hemodynamic variation in the operating room. The heart transplant recipient is at increased risk of coronary artery disease and renal insufficiency and should undergo careful preoperative evaluation. The patient with reactive airway disease is at increased risk of minor respiratory complications and should be encouraged to quit smoking. The patient with coronary artery disease and recent myocardial infarction may undergo ambulatory surgery without stress testing if functional capacity is adequate. The patient with obstructive sleep apnea is at increased risk of difficult tracheal intubation but the likelihood of airway obstruction and apnea following ambulatory surgery is unknown. CONCLUSION Ambulatory anesthesia is infrequently associated with adverse outcomes, however, knowledge regarding specific patient conditions is of generally low quality. Few prospective trials are available to guide management decisions.
Collapse
Affiliation(s)
- Gregory L Bryson
- Department of Anesthesiology, Head, Pre-Admission Units, The Ottawa Hospital, 1053 Carling Avenue, Ottawa, Ontario K1Y 4E9, Canada.
| | | | | | | | | | | | | | | | | | | |
Collapse
|